List Drug/Medicine Allergies : Reactions :
___________________________ ___________________________ If ‘NO KNOWN ALLERGIES’,
___________________________ ___________________________ Circle  NKA
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Do you have a LATEX sensitivity or allergy : (circle) Yes / No If so, What kind of reaction?_____________
Are you currently using any Eye Drops? Including any artificial tears, please list below:
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Current Medications :
(Including oral contraceptives, aspririn, over the counter medications and home remedies)
List Medications and Dosage :
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Social History :
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you are more
comfortable.
Do you drive? (circle) Yes / No
Do you smoke? (circle) Yes / No How many per day? ___________
Do you use smokeless tobacco? (circle) Yes / No
Do you drink alcohol? (circle) Yes / No How often? (circle) Rarely / Socially / Frequently
Do you use illegal drugs? (circle) Yes / No
Have you ever been exposed to or infected with the following : (circle all that apply)
Gonorrhea Hepatitis HIV Syphilis MRSA
Misc :
Are you Pregnant? (circle) Yes / No
Do you wear glasses? (circle ) Yes / No
Do you wear contact lenses? (Circle) Yes / No
Height? __________Weight? ___________
What is your PREFERRED PHARMACY, and in what CITY?_________________________________________
Is there any other information that we did not cover, that you would like us to know to better serve you?
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